Ureteral Reimplantation (Ureteroneocystostomy) - Operative Steps in Detail

Note: The query "urethral reimplantation" most likely refers to ureteral reimplantation (ureteroneocystostomy) - the operative procedure of reconnecting the ureter to the bladder. This is a standard urological/pediatric surgery. If you meant reimplantation of an artificial urinary sphincter cuff around the urethra, please let me know.

Overview and Indications

• Vesicoureteral reflux (VUR) - most common indication in children
• Ureteral stricture disease (benign or post-radiation)
• Iatrogenic ureteral injury (recognized or delayed)
• Planned single-stage surgery (diverticulectomy, partial cystectomy, distal ureterectomy)

Pre-operative Evaluation

• CT urogram or retrograde pyelogram to delineate the site and extent of ureteral pathology
• Voiding cystourethrogram (VCUG) for VUR grading
• Renal nuclear scan (MAG-3) for functional assessment
• Cystoscopy to evaluate bladder capacity, assess trigone, and confirm ureteral orifice position
• Urodynamics if concurrent bladder dysfunction is suspected

Surgical Approaches: Classification

I. NONREFLUXING EXTRAVESICAL APPROACH - Modified Lich-Gregoir (Adult)

Step 1: Patient Positioning & Access

• Supine position, low midline or Pfannenstiel incision
• Enter the space of Retzius (retropubic space)
• Identify the bladder and ureter

Step 2: Ureteral Identification and Mobilization

• Identify the ureter where it crosses the bifurcation of the iliac vessels
• Mobilize both cephalad and caudad, preserving periureteral adventitial tissue (maintains blood supply)
• Transect the ureter above the diseased segment; tie or clip the distal stump
• Place stay sutures on the proximal transected ureter
• Send distal margin for frozen section to exclude malignancy

Step 3: Bladder Mobilization

• Partially distend the bladder with ~150 mL sterile water (facilitates dissection)
• Dissect lateral pelvic gutters superiorly; push peritoneal reflection off the bladder dome using a sponge stick in a cephalad-medial sweeping motion
• Transect the ipsilateral medial umbilical ligament and urachus at the dome if needed
• Assess tension-free reach: approximate the ureter to the decompressed bladder dome to confirm no tension exists

Step 4: Creation of the Submucosal Tunnel (Detrusor Incision)

• Identify the reimplantation site on the posterior bladder wall, superior and medial to the native ureterovesical junction
• Incise the detrusor muscle extravesically using electrocautery, leaving the underlying mucosa intact
• Length of trough ~3 cm
• Create the trough down to the subepithelial layer
• Mobilize the lateral detrusor flaps to create space for the ureter within the trough

Step 5: Mucosal Entry

• Create a mucosal defect at the distal end of the tunnel, wide enough to accommodate the ureter
• This becomes the new ureteral orifice site

Step 6: Ureteral Spatulation and Anastomosis

• Spatulate the distal end of the transected ureter anteriorly (~5 mm)
• Pass the ureter through the tunnel so it lies in the detrusor trough
• Anastomose the ureteral end to the bladder mucosa with interrupted 4-0 or 5-0 absorbable sutures (polyglactin or polydiaxanone)
• Place a ureteral stent if desired (typically 4-6 Fr double-J stent)

Step 7: Closure of Detrusor Muscle

• Close the detrusor muscle flaps over the ureter with interrupted or running 2-0 or 3-0 absorbable sutures
• This creates the antireflux submucosal tunnel
• Ensure the tunnel is snug but not constrictive (a curved hemostat should pass alongside the ureter)

Step 8: Final Steps

• Place a large-bore Foley catheter
• Irrigate the bladder to test adequacy of anastomosis
• Place a pelvic drain anterior to the repair site, brought out via separate stab incision
• Close fascia with 0-loop polydioxanone; close skin

II. INTRAVESICAL (TRANSVESICAL) APPROACH - Refluxing Technique

Step 1-3: Same initial steps (positioning, ureteral mobilization, bladder mobilization)

Step 4: Anterior Cystotomy

• Make an anterior midline vertical cystotomy to gain intravesical access with the bladder partially distended
• Place stay sutures on bladder wall edges

Step 5: Creation of New Ureterovesical Orifice

• Pass a Kelly clamp through the cystotomy, directed posteriorly against the posterior bladder dome, lateralized to the side of ureteral pathology
• Create a posterior cystotomy over the Kelly clamp, large enough to accommodate the ureter
• Advance the clamp posteriorly through the bladder wall defect
• Grasp the stay sutures on the distal ureter end
• Withdraw the clamp, bringing the ureter into the bladder through the posterior wall defect - this becomes the new ureterovesical junction and neo-orifice

Step 6: Spatulation and Anastomosis

• Spatulate the ureter and anastomose to the mucosa of the neo-orifice
• Interrupted absorbable sutures (4-0 or 5-0)
• Place ureteral stent if needed

Step 7: Bladder Closure

• Close the cystotomy in a two-layer fashion with 2-0 polyglactin
• Fill with 200 mL sterile water to test closure and anastomosis
• Place pelvic drain; close fascia and skin

III. INTRAVESICAL ANTIREFLUX TECHNIQUES (Pediatric / VUR Context)

A. Cohen Cross-Trigonal Technique

1. Open the bladder with an anterior vertical cystotomy
2. Incise mucosa circumferentially around the ureteral orifice
3. Dissect and mobilize the intravesical ureter from Waldeyer's sheath (periureteral fibromuscular sheath)
4. Create a cross-trigonal submucosal tunnel directed toward the contralateral side of the trigone
5. Place the ureter within the tunnel (tunnel length = 3-5x ureteral diameter)
6. Anastomose the ureteral orifice to bladder mucosa at the end of the tunnel with fine absorbable sutures
7. Close any remaining mucosal defects
8. Close cystotomy; place Foley catheter

B. Politano-Leadbetter Technique

1. Open the bladder via anterior cystotomy
2. Dissect around the ureteral orifice and mobilize the ureter both intra- and extravesically
3. Create a new hiatus superolateral to the original, higher on the posterior bladder wall
4. Pass the ureter through the new hiatus
5. Create a submucosal tunnel from the new hiatus caudally to the original orifice site
6. Bring the ureter through the tunnel and anastomose at the original (or nearby) orifice position
7. Close the old hiatus and cystotomy

IV. AUGMENTED REPAIRS FOR LONGER DEFECTS

A. Psoas Hitch

1. Complete ureteral mobilization and transection as above
2. Fill bladder with 200 mL saline; mobilize bladder widely
3. Incise peritoneum lateral to obliterated umbilical ligaments bilaterally and transect the urachus
4. Blunt dissection allows the bladder to "drop" posteriorly into the space of Retzius
5. Identify the psoas minor tendon superior and lateral to the ipsilateral common iliac vessels
6. Suture the posterior bladder wall to the psoas minor tendon with 2-0 polyglactin sutures (2-3 sutures), capturing the detrusor - sutures oriented parallel to muscle fibers to avoid the genitofemoral nerve and femoral nerve
7. The ipsilateral bladder dome is displaced cephalad and fixed
8. Create a cystotomy on the superior-lateral aspect of the displaced bladder dome
9. Spatulate the ureter and perform a refluxing or nonrefluxing anastomosis (extravesical tunnel or direct)
10. Place ureteral stent before completing anastomosis
11. Place pelvic drain; close bladder; close abdomen

B. Boari Flap (Bladder Advancement Flap)

1. Complete ureteral mobilization
2. Widely mobilize the bladder as for psoas hitch
3. Mark a U-shaped or spiral flap on the anterior bladder wall; base width should be at least 4 cm (to preserve vascularity from the superior vesical artery)
4. Incise the flap; raise it off the bladder
5. Tubularize the flap around a stent (or suture it into a tube) creating a neoureter
6. Spatulate the native ureter and anastomose end-to-end to the apex of the flap tube
7. Roll/tubularize the flap around the anastomosis and suture closed
8. The base of the flap can be sutured to the psoas tendon (combined psoas hitch-Boari) for additional length
9. Close the bladder defect at the base of the flap
10. Place ureteral stent and pelvic drain; close

V. ROBOTIC/LAPAROSCOPIC TECHNIQUE

• Trocar placement: 3-4 ports in transperitoneal approach; assistant port on the contralateral side
• Incise the white line of Toldt; identify ureter crossing iliac vessels
• Ureter mobilized distally with periureteral tissue preserved
• Metal clip placed distal to diseased segment; distal stump closed
• Bladder mobilized with CO2 pneumoperitoneum maintained
• Psoas sutures placed under robotic visualization with care for genitofemoral nerve
• Ureteral spatulation, cystotomy, and anastomosis performed robotically with fine absorbable sutures
• Stent placed retrograde before anastomosis completion
• Pelvic drain placed; port closure

Postoperative Management

• Foley catheter: removed at 5-7 days (confirm no leak with cystogram)
• Ureteral stent: removed at 4-6 weeks cystoscopically
• Pelvic drain: removed when output is minimal (24-48 h)
• Follow-up renal ultrasound at 6 weeks and 3 months
• VCUG at 3 months post-op to confirm resolution of reflux
• Monitor for complications:
  • Ureterovesical stenosis / obstruction (~3%)
  • Persistent or contralateral VUR (~9% low-grade)
  • Urinary leak
  • Urinoma or hematoma

Success Rates

• Open surgical repair: 95-100% reflux resolution
• Robotic-assisted laparoscopic: comparable success, ongoing data accumulation
• Endoscopic injection (Deflux/STING): 70-90% depending on VUR grade (lower, non-durable)